Trigeminal Neuralgia, also known as tic douloureux, is sometimes described as the most excruciating pain known to humanity. The pain typically involves the lower face and jaw, although sometimes it affects the area around the nose and above the eye. This intense, stabbing, electric shock-like pain is caused by irritation of the trigeminal nerve, which sends branches to the forehead, cheek and lower jaw. It usually is limited to one side of the face. The pain can be triggered by an action as routine and minor as brushing your teeth, eating or the wind. Attacks may begin mild and short, but if left untreated, trigeminal neuralgia can progressively worsen.
Although trigeminal neuralgia cannot always be cured, there are treatments available to alleviate the debilitating pain. Normally, anticonvulsive medications are the first treatment choice. Surgery can be an effective option for those who become unresponsive to medications or for those who suffer serious side effects from the medications.
Causes
In trigeminal neuralgia, also called tic douloureux, the trigeminal nerve's function is disrupted. Usually, the problem is contact between a normal blood vessel — in this case, an artery or a vein — and the trigeminal nerve at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction.
Trigeminal neuralgia can occur as a result of aging, or it can be related to multiple sclerosis or a similar disorder that damages the myelin sheath protecting certain nerves. Trigeminal neuralgia can also be caused by a tumor compressing the trigeminal nerve.
Some people may experience trigeminal neuralgia due to a brain lesion or other abnormalities. In other cases, surgical injuries, stroke or facial trauma may be responsible for trigeminal neuralgia.
Triggers
A variety of triggers may set off the pain of trigeminal neuralgia, including:
Shaving
Touching your face
Eating
Drinking
Brushing your teeth
Talking
Putting on makeup
Encountering a breeze
Smiling
Washing your face
Symptoms
Most patients report that their pain begins spontaneously and seemingly out of nowhere. Other patients say their pain follows a car accident, a blow to the face or dental work. In the cases of dental work, it is more likely that the disorder was already developing and then caused the initial symptoms to be triggered. Pain often is first experienced along the upper or lower jaw, so many patients assume they have a dental abscess. Some patients see their dentists and actually have a root canal performed, which inevitably brings no relief. When the pain persists, patients realize the problem is not dental-related.
The pain of TN is defined as either type 1 or type 2.
TN1 is characterized by intensely sharp, throbbing, sporadic, burning or shock-like pain around the eyes, lips, nose, jaw, forehead and scalp. TN1 can get worse resulting in more pain spells that last longer.
TN2 pain often is present as a constant, burning, aching and may also have stabbing less intense than TN1.
TN tends to run in cycles. Patients often suffer long stretches of frequent attacks, followed by weeks, months or even years of little or no pain. The usual pattern, however, is for the attacks to intensify over time with shorter pain-free periods. Some patients suffer less than one attack a day, while others experience a dozen or more every hour. The pain typically begins with a sensation of electrical shocks that culminates in an excruciating stabbing pain within less than 20 seconds. The pain often leaves patients with uncontrollable facial twitching, which is why the disorder is also known as tic douloureux.
Treatments
To treat trigeminal neuralgia, your doctor usually will prescribe medications to lessen or block the pain signals sent to your brain.
Anticonvulsants. Doctors usually prescribe carbamazepine (Tegretol, Carbatrol, others) for trigeminal neuralgia, and it's been shown to be effective in treating the condition. Other anticonvulsant drugs that may be used to treat trigeminal neuralgia include oxcarbazepine (Trileptal), lamotrigine (Lamictal) and phenytoin (Dilantin, Phenytek). Other drugs, including clonazepam (Klonopin) and gabapentin (Neurontin, Gralise, others), also may be used.
If the anticonvulsant you're using begins to lose effectiveness, your doctor may increase the dose or switch to another type. Side effects of anticonvulsants may include dizziness, confusion, drowsiness and nausea. Also, carbamazepine can trigger a serious drug reaction in some people, mainly those of Asian descent, so genetic testing may be recommended before you start carbamazepine.
Antispasmodic agents. Muscle-relaxing agents such as baclofen (Gablofen, Lioresal) may be used alone or in combination with carbamazepine. Side effects may include confusion, nausea and drowsiness.
Botox injections. Small studies have shown that onabotulinumtoxinA (Botox) injections may reduce pain from trigeminal neuralgia in people who are no longer helped by medications. However, more research needs to be done before this treatment is widely used for this condition.
Surgery
Surgical options for trigeminal neuralgia include:
Microvascular decompression. This procedure involves relocating or removing blood vessels that are in contact with the trigeminal root to stop the nerve from malfunctioning. During microvascular decompression, your doctor makes an incision behind the ear on the side of your pain. Then, through a small hole in your skull, your surgeon moves any arteries that are in contact with the trigeminal nerve away from the nerve, and places a soft cushion between the nerve and the arteries.
If a vein is compressing the nerve, your surgeon may remove it. Doctors may also cut part of the trigeminal nerve (neurectomy) during this procedure if arteries aren't pressing on the nerve.
Microvascular decompression can successfully eliminate or reduce pain most of the time, but pain can recur in some people. Microvascular decompression has some risks, including decreased hearing, facial weakness, facial numbness, a stroke or other complications. Most people who have this procedure have no facial numbness afterward.
Brain stereotactic radiosurgery. In this procedure, a surgeon directs a focused dose of radiation to the root of your trigeminal nerve. This procedure uses radiation to damage the trigeminal nerve and reduce or eliminate pain. Relief occurs gradually and may take up to a month.
Brain stereotactic radiosurgery is successful in eliminating pain for the majority of people. If pain recurs, the procedure can be repeated. Facial numbness can be a side effect.
Alternative medicine
Alternative treatments for trigeminal neuralgia generally haven't been as well-studied as medications or surgical procedures, so there's often little evidence to support their use.
However, some people have found improvement with treatments, such as acupuncture, biofeedback, chiropractic, and vitamin or nutritional therapy. Be sure to check with your doctor before trying an alternative treatment because it may interact with your other treatments.
